The much-anticipated report into the accident that claimed the lives of footballer Emiliano Sala and pilot David Ibbotson has pointed to the pilot losing control of the aircraft in poor weather conditions, with lack of night flying qualifications and instrument flying experience, and “probable” carbon monoxide poisoning, all contributory factors.
Published by the UK Air Accidents Investigation Branch (AAIB) on March 13, the report said the Piper PA-46-310P Malibu, U.S. registration N264DB and piloted by Ibbotson, departed from Nantes Airport, France, at 1906 hrs on Jan. 21, 2019, after several delays during the day, carrying Sala “on a commercial basis” to Cardiff Airport in the UK.
The last radio contact with the aircraft was with Jersey ATC at 2012 hours when the pilot asked for a further descent to remain in VMC. At 2016 hours, “probably while maneuvering to avoid poor weather,” the aircraft was lost from radar and struck the sea 22 nm north-northwest of Guernsey. “The pilot made no distress call that was recorded by ATC,” the report said.
Significantly, the findings highlight the illegal nature of the flight: “Neither the pilot nor aircraft had the required licenses or permissions to operate commercially,” said the AAIB, noting that it has already, since the accident, taken safety action to raise awareness of the risks associated with unlicensed charter flights, while improving guidance for maintenance personnel undertaking inspections of exhaust systems.
Ibbotson, 59, held an EASA PPL and FAA PPL, and around 3,500 hours of flying experience. Around 30 of these hours were on the Piper Malibu, with about 20 hours in the previous 90 days. He held a valid CAA Instrument Rating (Restricted) but no night rating and no FAA instrument rating, and the investigation found no evidence of the pilot completing any night flying training, although he had flown several times at night during the previous 12 months. The AAIB does not acknowledge that in the U.S. night flying is part of the PPL, not a separate rating, although in any case Ibbotson needed a CPL for this flight.
His EASA SEP (single-engine piston) rating was due to expire in November 2018 and “the investigation found no record of it being renewed,” although he had completed a biennial flight review (BFR) for his FAA license. The AAIB noted the pilot “had been authorized in error to fly the PA-46 as pilot-in-command (PIC) during both the day and night. It was not established whether the pilot had undertaken the FAA’s equivalent ‘complex aircraft training’ for the PA-46.”
The pilot had “little experience of flying in instrument meteorological conditions (IMC) or operating under instrument flight rules (IFR),” the report said, as much of his experience was in parachute dropping operations.
Regarding the commercial nature of the flight, the report said: “The pilot’s records showed that he had been paid a fee for flights on numerous occasions. Other evidence showed that he was to be paid a fee for the accident flight.”
The pilot’s body was not recovered but the AAIB said post-mortem tests on the passenger “showed a blood carboxyhemoglobin (COHb) level of 58 percent, and the pathologist considered that he would almost certainly have been ‘deeply unconscious’ at impact.”
According to the AAIB, there was “no CO detector with an active warning” in the aircraft, “which might have alerted the pilot to the presence of CO in time for him to take mitigating action.”
The report said N264DB should have been operated in accordance with Part 135 as it was being operated as a charter flight, and this would have required the pilot to have a CPL and for pressure testing of the exhaust system.
In response to the report, the European Business Aviation Association (EBAA), the British Business and General Aviation Association (BBGA) and The Air Charter Association (ACA) called on governments worldwide to take the issue of illegal charter flights more seriously.
“Authorities must make additional resources available to actively prosecute offenders who flout the law. There need to be far higher sentences, more substantial fines, the removal of pilots’ licenses and seizure of aircraft for those people who, despite knowing the law, operate as if they weren’t subject to any of it,” they said in a joint statement.